Differential Diagnosis for Postmenopausal Vaginal Bleeding
- Single most likely diagnosis
- Cervical cancer: The presence of a 3-cm friable mass on the ectocervix that is actively bleeding, in the context of postmenopausal vaginal bleeding, strongly suggests cervical cancer. The patient's history of smoking, which is a risk factor for cervical cancer, further supports this diagnosis.
- Other Likely diagnoses
- Endometrial cancer: Although the pelvic ultrasonography shows a thin endometrial stripe, which reduces the likelihood of endometrial cancer, it cannot be entirely ruled out without further investigation, such as an endometrial biopsy. The patient's obesity and postmenopausal status are risk factors for endometrial cancer.
- Endometrial atrophy or polyps: These conditions can cause postmenopausal bleeding, especially in the context of a thin endometrial stripe on ultrasonography. However, the presence of a cervical mass makes these diagnoses less likely.
- Do Not Miss diagnoses
- Uterine sarcoma: Although rare, uterine sarcomas can present with postmenopausal bleeding and a mass. Given the potential for aggressive behavior and poor prognosis, it is crucial not to miss this diagnosis.
- Ovarian cancer: Despite the absence of adnexal masses on ultrasonography, ovarian cancer can sometimes present with vaginal bleeding. The patient's family history of breast cancer (which can be associated with BRCA mutations, also increasing the risk of ovarian cancer) makes this a "do not miss" diagnosis.
- Rare diagnoses
- Vaginal cancer: This is a rare malignancy that can present with vaginal bleeding. The presence of a cervical mass and the patient's symptoms make cervical cancer more likely, but vaginal cancer should be considered if the biopsy of the cervical mass does not reveal cancer.
- Metastatic cancer to the cervix or uterus: Although rare, cancers from other primary sites (e.g., breast, colon) can metastasize to the cervix or uterus, causing bleeding. The patient's family history of breast cancer slightly increases the likelihood of this rare scenario.